At the conclusion of the session, participants should be able to:<br />1.  Understand the pathophysiology of concussions i...
Sports Concussions in the News<br />
Concussions in Sports<br />CDC estimates 3.8 million sports- and recreation-related concussions in U.S. every year<br />Te...
Concussions in Sports<br />Youth hockey:  23.15 concussions/1000 player game-hours<br />NHL:  29.59 concussions/1000 playe...
VALID   |   RELIABLE   |   SAFE<br />Mark R. Lovell, Ph.D., FACPN<br />Professor and Director<br />UPMC Sports Medicine Co...
Neurometabolic Cascade Following Injury<br />
Neurometabolic Cascade Following Injury<br />
Evolving Definition of Concussion<br />CDC Physicians Toolkit 2007<br />REGARDING CEREBRAL CONCUSSION……<br />A concussion ...
Commonly Reported Symptoms<br />High School and College Athletes-within 3 days of injury<br />SYMPTOM				PERCENT	<br /># 1...
Symptom Evaluation/Clinical Interview: <br />What is Asymptomatic?<br />IS NOT “How are you feeling?” or “Do You Have a He...
COMMON SIGNS/SYMPTOMS?<br />Headache<br />Dizziness<br />Confusion<br />Memory Loss (amnesia)<br />Blurred or double visio...
Risk Factors for Poor Recovery<br />Effects of Multiple injuries<br />(more is not better)<br />Younger Age? <br />(being ...
Cumulative Effects of Repetitive Injury<br />Past studies have suggested that repetitive trauma in athletes is associated ...
 Athletes with 3 or more prior mTBI’s were more likely to </li></ul>demonstrate markers of concussion during the period of...
Age and Recovery from mTBI<br />Younger age has been associated  with prolonged recovery.<br /><ul><li>High school athlete...
  High school athletes demonstrated longer lasting memory  deficits  compared to college athletes (Sim et al., J. Neurosur...
  High school athletes had prolonged recovery times compared to NFL athletes (Pellman, Lovell et al.,Neurosurgery, 2003).<...
Neuropsychological Test PerformanceMale vs. Female AthletesT Scores with Mean of 50 and S.D. of 10(Colvin, Lovell et al., ...
Post-Concussion Syndrome<br />Chronic Headache (Migraine type)<br />Photo/Phonosensitivity<br />Nausea<br />Chronic Fatigu...
Management of MTBI: Topics of Concern<br /><ul><li>Grading systems ineffective/not data based.
CT and MRI insensitive to subtleties of injury.
Self-report predicates management directives.
Variability in clinician recommendations.
Lack of education and awareness of injury.
Inadequate/Improper recommendations from 	ED/Trauma Departments.</li></li></ul><li>
CONCUSION EVALUATION TIMELINE<br />Pre-Season<br />1-3 Days<br />Follow-ups<br />As needed<br />First<br />Follow-up<br />...
Concussion: The Diagnostic, Management and Return to Play Dilemma<br />How to recognize the moods of an Irish setter<br />
History and Development<br /> of  ImPACT<br />
The Pittsburgh Steelers Program<br />First program to monitor professional athletes<br />Resulted in League Wide Program i...
Computer-Based Neurocognitive Testing<br />Currently Available Programs<br />Cogsport<br />Headminders (CRI)<br />ANAM<br ...
Immediate Post-Concussion Assessment <br />and Cognitive Testing<br />Mark R. Lovell, Ph.D., FACPN, CEO, Chairman and Deve...
Development of ImPACT:A Tradition of Research<br />1988- 1994	Steelers Project (pre-ImPACT)<br /> 1994 - 1996	Test Develop...
 Large-Scale Programs in US/Abroad<br /><ul><li>Ontario Ice Hockey Federation
Ontario Ice Hockey League
Western Ice Hockey League
Australian Rugby
New Zealand Rugby
South African Rugby
Irish Rugby
Swedish World Cup Soccer
600 + Universities in US
Many Neuropsychology Clinics
Major League Baseball Umpires
Army, Navy, Air Force Academies
US Military Special Ops (Army)
US Military Navy Seals
US Olympic Team (sliding sports)
All NFL Teams
 All NHL Teams
 All Major League Baseball
 IRL, CHAMP Car (Racing)
 Formula 1 Racing
 USA Olympic Ice Hockey
 USA Ice Hockey
4,000+ High Schools
200+ Clinics
 USA Ski/Snow Board Team
USA Soccer Juniors
Major League Soccer
 Six NBA Teams (Basketball)
Cirque Du Soleil
WWE (Pro wrestling)</li></ul>*Mandated by league or team<br />
Why Bother with ImPACT?<br />Dispelling Common Myths of Concussion<br />“The athlete’s know when they are better”<br />“Ju...
ImPACT: Design and Structure<br />Designed to evaluate multiple aspects<br />    of cognitive functioning in brief period<...
 Cognitive Speed
 Interaction of Memory and Speed </li></ul>(Cognitive Efficiency)©<br /><ul><li>Self-report of symptoms</li></li></ul><li>...
 Automatically Computer Scored</li></ul>Desktop and On-Line Versions Available<br /><ul><li>Extensive normative data avail...
Myths and Misperceptions about ImPACT<br />“ImPACT is unreliable”<br />(multiple studies have showed that it is)<br />“ImP...
Pressure to Play in Sports: Can We Trust What the Athlete Tells Us?<br />We can’t trust a concussed athlete to diagnose th...
“When it comes to concussion, <br />don’t believe me when I tell <br />you that I’m OK ”<br />NFL Athlete, 2010<br />
Never Believe a Cheerleader (Or any other athlete)<br />
Pros/Cons of ImPACT Testing When Symptomatic<br />PROS<br />Helps todetermine severityof injury<br />Helps to determines p...
Unique Contribution of Neurocognitive Testing to Concussion Management<br />Testing reveals<br />cognitive deficits<br />i...
Current Status of Concussion Management<br />
LYSTEDT’S LAWState of Washington<br /><ul><li>Zach Lystedt returned to play by coach after two   injuries in one game
Second injury produced malignant brain swelling and permanent brain damage.
State of Washington passed law requiring evaluation prior to return to play.
20 states have passed some type of concussion legislation.
24 states have pending Bills</li></li></ul><li>CURRENT LEGLISLATION<br />
What’s happening in Minnesota?<br />15-year-old Kayla Meyer of New Prague: "just need to realize that their health is more...
Minnesota Concussion Law<br />Signed Gov Dayton on May 11 2001 –effective Sept 1st 2011 <br />Applies to any organization ...
MANAGING CONCUSSION<br />Promoting a Safe Return-to-Play<br />
CURRENT MANAGEMENT GUIDELINES<br />“When in doubt, sit them out”<br />No athlete should play with symptoms<br />(both at r...
ImPACT CONCUSSION PROTOCOLOn The Field of Play<br /><ul><li>On-field evaluation</li></ul>- Signs/symptoms evaluation<br />...
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Concussion noname

  1. 1. At the conclusion of the session, participants should be able to:<br />1.  Understand the pathophysiology of concussions in children and the significance with regard to symptoms, management and recovery.<br />2.  Understand the clinical and diagnostic tools available to assist in the evaluation and management of children with concussions.<br />3.  Understand the signs and symptoms of concussive or minor traumatic brain injuries in children.<br />4.  Be aware of the new MN Concussion Law for children and return to activity requirements.<br />5.  Understand the role of adjunctive assessment tools in the management of children with concussions, including computerized neuropsychological testing.<br />
  2. 2. Sports Concussions in the News<br />
  3. 3. Concussions in Sports<br />CDC estimates 3.8 million sports- and recreation-related concussions in U.S. every year<br />Team sports with most ER visits<br />Ice hockey<br />Football<br />Soccer<br />Cheerleading<br />Snow skiing, bicycling, playground<br />
  4. 4. Concussions in Sports<br />Youth hockey: 23.15 concussions/1000 player game-hours<br />NHL: 29.59 concussions/1000 player game-hours<br />Women’s hockey has highest rate of concussion of any NCAA sport, even though checking is not allowed<br />
  5. 5. VALID | RELIABLE | SAFE<br />Mark R. Lovell, Ph.D., FACPN<br />Professor and Director<br />UPMC Sports Medicine Concussion Program<br />Chairman and Developer<br />ImPACT Applications, InC.<br />WHAT IS A CONCUSSION?<br />A Mild Traumatic Brain Injury<br />A Change in brain function that occurs when there is a blow to the head and the brain is shaken violently<br />This results in chemical changes in the brain<br />The brain is more vulnerable to injury while it is recovering<br />Additional injury during the recovery period is very dangerous<br />
  6. 6.
  7. 7.
  8. 8.
  9. 9.
  10. 10.
  11. 11. Neurometabolic Cascade Following Injury<br />
  12. 12. Neurometabolic Cascade Following Injury<br />
  13. 13. Evolving Definition of Concussion<br />CDC Physicians Toolkit 2007<br />REGARDING CEREBRAL CONCUSSION……<br />A concussion (or mild traumatic brain injury) is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural brain injury, and is typically associated with normal structural imaging findings (CT Scan, MRI). Concussion may or may not involve a loss of consciousness. Concussion results in a constellation of physical, cognitive, emotional, and sleep-related symptoms. Recovery is a sequential process and symptoms may last from several minutes to days, weeks, months, or even longer in some cases.” <br />
  14. 14. Commonly Reported Symptoms<br />High School and College Athletes-within 3 days of injury<br />SYMPTOM PERCENT <br /># 1 Headache 71 % <br /># 2 Feeling slowed down 58 % <br /># 3 Difficulty concentrating 57 % <br /># 4 Dizziness 55 % <br /># 5 Fogginess 53 % <br /># 6 Fatigue 50 % <br /># 7 Visual Blurring/double vision 49 % <br /># 8 Light sensitivity 47 % <br /># 9 Memory dysfunction 43 % <br /># 10 Balance problems 43 % <br />Lovell, Collins et al., 2004; N = 215 <br />
  15. 15. Symptom Evaluation/Clinical Interview: <br />What is Asymptomatic?<br />IS NOT “How are you feeling?” or “Do You Have a Headache?”<br />IS a series of questions inquiring about subtleties of injury<br />“Do you have a pressure in your head that increases as day progresses?”<br />“Are you more sensitive to lights and noises than normal?”<br />“Do you become dizzy when looking up/down, turning head, standing quickly?”<br />“Do you feel more fatigued than normal at the end of the day?”<br />“Do you have blurred or fuzzy vision while reading or difficulty reading?”<br />“Do you feel more distractible in school than normal?”<br />“Do you feel a sense of fogginess during the day?”<br />“Do you have difficulty falling/staying asleep?”<br />“Have you or your parents noticed that you are more irritable than normal?”<br />“Asymptomatic” is not an easily defined term, although it is at the core of concussion management<br />
  16. 16. COMMON SIGNS/SYMPTOMS?<br />Headache<br />Dizziness<br />Confusion<br />Memory Loss (amnesia)<br />Blurred or double vision, seeing stars<br />Nausea<br />Light or noise sensitivity<br />Balance problems<br />Loss of consciousness is rare (<10 percent)<br />
  17. 17. Risk Factors for Poor Recovery<br />Effects of Multiple injuries<br />(more is not better)<br />Younger Age? <br />(being young is not always better)<br />Gender? <br />(its just not a boys injury)<br />
  18. 18. Cumulative Effects of Repetitive Injury<br />Past studies have suggested that repetitive trauma in athletes is associated with poorer outcome.<br /><ul><li> Athletes with 3 or more mTBI’s were 3 times more likely to have an additional injury (Guskiewicz et al, JAMA, 2003)
  19. 19. Athletes with 3 or more prior mTBI’s were more likely to </li></ul>demonstrate markers of concussion during the period of <br />our study (Collins, Lovell et al., Neurosurgery, <br />
  20. 20. Age and Recovery from mTBI<br />Younger age has been associated with prolonged recovery.<br /><ul><li>High school athletes had prolonged recovery times compared to college athletes (Field et al., J. Pediatrics, 2004).
  21. 21. High school athletes demonstrated longer lasting memory deficits compared to college athletes (Sim et al., J. Neurosurgery, 2008)
  22. 22. High school athletes had prolonged recovery times compared to NFL athletes (Pellman, Lovell et al.,Neurosurgery, 2003).</li></li></ul><li>Sex and Recovery from mTBI<br />Initial studies have suggested that females <br /> may be at greater risk compared to males.<br /><ul><li>In sports played by both sexes, females sustained a higher</li></ul>rate of mTBI than males (Comstock et al, JAT, 2007). <br />Based on high school and NCAA data.<br /><ul><li>In a large sample of Junior high, HS and Collegiate soccer</li></ul>athletes, females had longer recovery time than males<br />(Colvin, Lovell et al., AOSSM, 2008).<br />
  23. 23. Neuropsychological Test PerformanceMale vs. Female AthletesT Scores with Mean of 50 and S.D. of 10(Colvin, Lovell et al., AJSM, 2009)<br />p.<.004<br />NS<br />NS<br />p.<.00001<br />Reaction Time<br />Symptoms<br />Verbal Memory<br />Proc. Speed<br />N=238 (143 Females, 95 Males)<br />Groups were not different at baseline and were matched for age and BMI<br />
  24. 24.
  25. 25. Post-Concussion Syndrome<br />Chronic Headache (Migraine type)<br />Photo/Phonosensitivity<br />Nausea<br />Chronic Fatigue<br />Vestibular Deficits<br />Mood Issues-Depression/Anxiety<br />Sleep Deficits<br />Cognitive Deficits (potentially severe)<br />Academic Difficulties<br />Chronic traumatic encephalopathy?<br />
  26. 26.
  27. 27. Management of MTBI: Topics of Concern<br /><ul><li>Grading systems ineffective/not data based.
  28. 28. CT and MRI insensitive to subtleties of injury.
  29. 29. Self-report predicates management directives.
  30. 30. Variability in clinician recommendations.
  31. 31. Lack of education and awareness of injury.
  32. 32. Inadequate/Improper recommendations from ED/Trauma Departments.</li></li></ul><li>
  33. 33. CONCUSION EVALUATION TIMELINE<br />Pre-Season<br />1-3 Days<br />Follow-ups<br />As needed<br />First<br />Follow-up<br />Baseline <br />Testing<br />CONCUSSION<br />REMOVE<br />FROM<br />PLAY<br />Re-Evaluation<br />Rest<br />Gradual Exertion<br />At school or<br />clinic<br />Return to Play<br />
  34. 34. Concussion: The Diagnostic, Management and Return to Play Dilemma<br />How to recognize the moods of an Irish setter<br />
  35. 35. History and Development<br /> of ImPACT<br />
  36. 36. The Pittsburgh Steelers Program<br />First program to monitor professional athletes<br />Resulted in League Wide Program in NFL<br />Resulted in adoption by other sports/leagues<br />Resulted in the development of ImPACT<br />
  37. 37. Computer-Based Neurocognitive Testing<br />Currently Available Programs<br />Cogsport<br />Headminders (CRI)<br />ANAM<br />ImPACT<br />Explosion of research since 2001<br />
  38. 38. Immediate Post-Concussion Assessment <br />and Cognitive Testing<br />Mark R. Lovell, Ph.D., FACPN, CEO, Chairman and Developer<br />Joseph C. Maroon, M.D., Co-Founder<br />Michael W. Collins, Ph.D., Co-Founder<br />ImPACT was developed to provide a scientific way <br />of evaluating readiness to return-to-play <br />following concussion<br />
  39. 39. Development of ImPACT:A Tradition of Research<br />1988- 1994 Steelers Project (pre-ImPACT)<br /> 1994 - 1996 Test Development<br /> 1996 - 1997 Field Testing (Multiple Sites)<br /> 1998 - 2000 NCAA/NAN Studies<br />2000 UPMC Program Established<br />2001 - 2006 NIH fMRI Study ($2.8 Million)<br /> 2003 - 2007 CDC Child Study ($2.0 Million)<br /> 2000 - 2010 Reliability/Validity Data Published <br /> 1999 - 2010  Over 80 Peer Reviewed Manuscripts<br /> 3 Textbooks / 55 Chapters<br />
  40. 40. Large-Scale Programs in US/Abroad<br /><ul><li>Ontario Ice Hockey Federation
  41. 41. Ontario Ice Hockey League
  42. 42. Western Ice Hockey League
  43. 43. Australian Rugby
  44. 44. New Zealand Rugby
  45. 45. South African Rugby
  46. 46. Irish Rugby
  47. 47. Swedish World Cup Soccer
  48. 48. 600 + Universities in US
  49. 49. Many Neuropsychology Clinics
  50. 50. Major League Baseball Umpires
  51. 51. Army, Navy, Air Force Academies
  52. 52. US Military Special Ops (Army)
  53. 53. US Military Navy Seals
  54. 54. US Olympic Team (sliding sports)
  55. 55. All NFL Teams
  56. 56. All NHL Teams
  57. 57. All Major League Baseball
  58. 58. IRL, CHAMP Car (Racing)
  59. 59. Formula 1 Racing
  60. 60. USA Olympic Ice Hockey
  61. 61. USA Ice Hockey
  62. 62. 4,000+ High Schools
  63. 63. 200+ Clinics
  64. 64. USA Ski/Snow Board Team
  65. 65. USA Soccer Juniors
  66. 66. Major League Soccer
  67. 67. Six NBA Teams (Basketball)
  68. 68. Cirque Du Soleil
  69. 69. WWE (Pro wrestling)</li></ul>*Mandated by league or team<br />
  70. 70. Why Bother with ImPACT?<br />Dispelling Common Myths of Concussion<br />“The athlete’s know when they are better”<br />“Just wait two weeks and return them to play”<br />“Don’t test the athlete until they are symptoms free”<br />
  71. 71. ImPACT: Design and Structure<br />Designed to evaluate multiple aspects<br /> of cognitive functioning in brief period<br />Subtests measures multiple cognitive<br /> processes<br /><ul><li> Verbal and Visual Memory
  72. 72. Cognitive Speed
  73. 73. Interaction of Memory and Speed </li></ul>(Cognitive Efficiency)©<br /><ul><li>Self-report of symptoms</li></li></ul><li>ImPACT: Post-Concussion Evaluation<br />Demographic / Concussion History Questionnaire<br />Concussion Symptom Scale<br /><ul><li>21 Item Likert Scale (e.g. headache, dizziness, nausea, etc)</li></ul>8 Neurocognitive Measures<br /><ul><li>Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary Scores</li></ul>Detailed Clinical Report<br /><ul><li> Outlines Demographic, Symptom, Neurocognitive Data
  74. 74. Automatically Computer Scored</li></ul>Desktop and On-Line Versions Available<br /><ul><li>Extensive normative data available from ages 11-60</li></li></ul><li>What ImPACT Is and Isn’t:<br />IS a useful and reliable/validconcussion management program.<br />IS atoolto help determine recovery from injury.<br /> IS a toolto help manage concussion-(e.g. return to exertion, return to academics, return to play). <br />IS atoolto help communicate post-concussion status to coaches, parents, clinicians.<br />IS NOT a substitute for medical evaluation/treatment<br />
  75. 75. Myths and Misperceptions about ImPACT<br />“ImPACT is unreliable”<br />(multiple studies have showed that it is)<br />“ImPACT has not been validated”<br />(it has) <br />“ImPACT is Too Expensive”<br />(it is not)<br />
  76. 76. Pressure to Play in Sports: Can We Trust What the Athlete Tells Us?<br />We can’t trust a concussed athlete to diagnose their own injury<br />Athletes are notorious for hiding symptoms<br /> Studies suggest that up to50% of athletes experience <br /> concussion symptoms per yearbut only 10 percent report<br />Most SIS cases are known to have played with symptoms<br />
  77. 77. “When it comes to concussion, <br />don’t believe me when I tell <br />you that I’m OK ”<br />NFL Athlete, 2010<br />
  78. 78. Never Believe a Cheerleader (Or any other athlete)<br />
  79. 79. Pros/Cons of ImPACT Testing When Symptomatic<br />PROS<br />Helps todetermine severityof injury<br />Helps to determines prognosis for outcome<br />(Iverson, Collins Lovell et al, CJSM 2007)<br />Guides management for levels of physical/cognitive exertion<br />Helps to determine specific academic needs/accommodations<br />Objectifies injury (it becomes real when they<br /> Legitimizes injury to athletes, parents, coaches, physicians<br /> Helps to establish therapeutic bond amongst all parties<br />CONS<br />Potential for exacerbation of symptoms<br /> Requires time commitment from ATC/Physician, etc<br />
  80. 80. Unique Contribution of Neurocognitive Testing to Concussion Management<br />Testing reveals<br />cognitive deficits<br />in asymptomatic<br />athletes within 4 <br />days post-concussion<br />N=215, MANOVA p<.000000 (Fazio, Lovell, Collins et al., Neurorehabilitaiton, 2007<br />
  81. 81.
  82. 82. Current Status of Concussion Management<br />
  83. 83. LYSTEDT’S LAWState of Washington<br /><ul><li>Zach Lystedt returned to play by coach after two injuries in one game
  84. 84. Second injury produced malignant brain swelling and permanent brain damage.
  85. 85. State of Washington passed law requiring evaluation prior to return to play.
  86. 86. 20 states have passed some type of concussion legislation.
  87. 87. 24 states have pending Bills</li></li></ul><li>CURRENT LEGLISLATION<br />
  88. 88. What’s happening in Minnesota?<br />15-year-old Kayla Meyer of New Prague: "just need to realize that their health is more important than the game sometimes. They need to really take care of themselves for the future."<br />
  89. 89. Minnesota Concussion Law<br />Signed Gov Dayton on May 11 2001 –effective Sept 1st 2011 <br />Applies to any organization that organizes a youth athletic activity for which an activity fee is charged <br />Coaches must have training on concussions <br />Information must be made available to the parent regarding the risks of concussions.<br />Must remove player (18 and under) from all activity if they have symptoms or suspected of having a concussion<br />Must have evaluation by a provider trained and experienced in evaluating and managing concussions and permission to again participate in the activity.<br />
  90. 90. MANAGING CONCUSSION<br />Promoting a Safe Return-to-Play<br />
  91. 91.
  92. 92. CURRENT MANAGEMENT GUIDELINES<br />“When in doubt, sit them out”<br />No athlete should play with symptoms<br />(both at rest and following exertion)<br /> Athlete should be back to baseline level on<br />neurocognitive testing (e.g. ImPACT)<br />1st-3rd International Symposia On Concussion in Sport<br />
  93. 93. ImPACT CONCUSSION PROTOCOLOn The Field of Play<br /><ul><li>On-field evaluation</li></ul>- Signs/symptoms evaluation<br />- Mental status testing on field<br /> Orientation, concentration, anterograde/retrograde amnesia<br /><ul><li>Symptoms may worsen with physical exertion
  94. 94. Any positive findings should result in removal </li></ul>WHEN IN DOUBT SIT THEM OUT!<br />
  95. 95. OFF THE FIELD OF PLAY<br />Evaluate athlete with ImPACT<br /><ul><li>Consultation with Neuropsychologist</li></ul>Compare results to baseline<br /> Evaluate symptoms and assess balance<br /> WHEN SYMPTOM FREE FOR TWO DAYS:<br /><ul><li>Begin light exercise (walking, jogging, etc)
  96. 96. Progress to Moderate exercise (running, lifting)
  97. 97. Progress to heavy non-contact (sprinting)
  98. 98. Return to practice/play</li></ul>If symptoms occur at a level, go back one level<br />
  99. 99. OUR TREATMENT PHILOSOPHY<br />Initial treatment through REST<br />Approximately 85% return to normal<br /> 15% of young patient’s do not recover<br /> on own (within 3 to 4 weeks)<br /><ul><li>Medication management?
  100. 100. Interface with the schools</li></li></ul><li>INTERFACING WITH THE SCHOOLS<br />
  101. 101.
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  106. 106.
  107. 107.
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  117. 117.
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  119. 119.
  120. 120.
  121. 121.
  122. 122.
  123. 123.
  124. 124.
  125. 125.
  126. 126.
  127. 127. The ImPACT Applications, Inc. software is a diagnostic tool that provides basic data related to neurocognitive functioning. The software does not provide treatment recommendations or a specific medical diagnosis with respect to any particular end user. Training provided or facilitated by ImPACT Applications, Inc. on the use of its software is intended to provide users with the ability to properly administer the tests embedded in the software and to become familiar with the types of data generated by the software. Treatment decisions that you and/or your organization make based on the data generated by the software is in you and/or your organization’s sole and absolute discretion. By participating in the training, you and your organization acknowledge and agree that ImPACT Applications, Inc., its officers, directors, employees, or agents and affiliates and their respective successors and assigns will not be held liable for claims of medical malpractice, practicing medicine without a license or similar claims made by you, your organization or any third party. To the fullest extent permitted by applicable law, you and your organization agree to hold ImPACT Applications, Inc., its officers, directors, employees, agents, and affiliates and their respective successors and assigns harmless and to indemnify ImPACT Applications Inc. and its officers, directors, employees, agents, and affiliates and their respective successors and assigns against any and all such claims. <br />
  128. 128. Copyright © 2011 by ImPACT Applications, Inc. <br />All rights reserved.  No part of this publication maybe reproduced in whole or in part or transmitted in any form or by any means without the prior written permission of ImPACT Applications, Inc.  For information regarding permission, please write to ImPACT Applications, Inc., LRUSSO@impacttest.com<br />ImPACT™ and associated logos are trademarks of ImPACT Applications, Inc.<br />
  129. 129. ImPACT™ and the ImPACT Logo are trademarks of ImPACT Applications, Inc. and are used herein with the express written permission of ImPACT Applications, Inc. and may not be duplicated, removed or altered without ImPACT Applications, Inc.’s written consent.  <br />
  130. 130. Thank you!<br />Questions?<br />Joseph Petronio, MD<br />Director of Pediatric Neurosurgery<br />Children’s Hospitals and Clinics of MN<br />joseph.petronio@childrensmn.org<br />(612) 343-2121<br />
  131. 131. Sports Concussions in the News<br />
  132. 132.
  133. 133. Fundamentals of Concussion Management<br />

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